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Adderall 30mg QID in the ED for someone who came in manic

Ativan 12mg daily (3mg QID) for a patient w/ history of catatonia

I inherited a few patients who had been on lexapro to 40mg for years, never having tried a second antidepressant or augmentation--still with depression. None of these patients had OCD.
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Coupd'Cat said:
Adderall 30mg QID in the ED for someone who came in manic

Ativan 12mg daily (3mg QID) for a patient w/ history of catatonia

I inherited a few patients who had been on lexapro to 40mg for years, never having tried a second antidepressant or augmentation--still with depression. None of these patients had OCD.
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But this was is very correct and not wrong. Guidelines often recommend trying up to 20-24mg/day. I've seen patients that were very severe and only fully improved with 18mg/day, and in those cases you really don't want to discontinue it before discharge.

I think I saw a halloo 80mg once time, that is probably the highest I've seen.
 
brazilianpsych said:
But this was is very correct and not wrong. Guidelines often recommend trying up to 20-24mg/day. I've seen patients that were very severe and only fully improved with 18mg/day, and in those cases you really don't want to discontinue it before discharge.

I think I saw a halloo 80mg once time, that is probably the highest I've seen.
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True--I am just contemplating the process of down-titration it on the outpatient side. Haven't come across much evidence base, open to papers/others' experience.
 
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Coupd'Cat said:
True--I am just contemplating the process of down-titration it on the outpatient side. Haven't come across much evidence base, open to papers/others' experience.
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Yeah there's no literature. If someone had a severe catatonia due to either primary psych or a medical condition that necessitated being discharged on high dose benzos, my approach is to go slow over months after treatment for the underlying condition has been addressed if possible. I have not seen these patients be at risk of use disorder. Ideally you also want to loop in a family member or two who can be a second set of eyes bc patients are often not aware of it when catatonia signs creep back in.

Some of these patients end up on some amount of chronic benzo (although usually a more normal dose) permanently and that's just what it is. One of the categories of patients where chronic benzos can be completely appropriate.

As a CL psychiatrist who is often the person putting patients on these high dose benzos during the inpatient stay, if they get discharged from medicine to home I always do try and get my note and contact info to the outpatient psychiatrist because we see these patients all the time but I know it's not routine in most practices.
 
10 years old on 18 mg total Risperidone… the kid was on the spectrum, and PCP was trying their best.. the kid was restless, running all the time (duh), and drove the staff crazy. Tapered down slowly, started a stimulant, and later a tiny dose of Abilify.. he was doing great.

This one makes me cringe... Adderall 80mg total (pt insisted on 10mg tabs). I refused, but I was a resident, and my attending said, “they have been on this dose for years”, still refused, and pt was transferred to that attending.

Another kid on the spectrum… vyvanse and Ritalin IR (don’t recall doses but mid doses). Zoloft, Wellbutrin, Depakote, and guanfacine (higher doses). I kept scratching my head about what to do (after discontinuing Ritalin, of course). Tapered off one by one, the kid ended up on Vyvanse, guanfacine, and Zoloft.


A 9 y/o with mild ID, anxiety and ADHD. Said that they were "hearing voices" after getting into a fight with their cousin... NP Dx: Schizophreniform:bang:, Risperidal 4mg. Discharge dx: Social anxiety, mild ID, ADHD. Concerta and Zoloft... and the kid was able to sit down, learn and read.

I have seen kids with clear ADHD on antipsychotics.. Seroquel 600mg stands out in my mind. The NP was telling me that it was the most challenging case they had. They did not listen to my advice (after they asked for it, and this is not someone I am supervising). I talked to their attending, and things went ok. GET THE KID ON A STIMULANT DAMMIT.

I can keep going on and on.
 
WVpsych said:
10 years old on 18 mg total Risperidone… the kid was on the spectrum, and PCP was trying their best.. the kid was restless, running all the time (duh), and drove the staff crazy. Tapered down slowly, started a stimulant, and later a tiny dose of Abilify.. he was doing great.

This one makes me cringe... Adderall 80mg total (pt insisted on 10mg tabs). I refused, but I was a resident, and my attending said, “they have been on this dose for years”, still refused, and pt was transferred to that attending.

Another kid on the spectrum… vyvanse and Ritalin IR (don’t recall doses but mid doses). Zoloft, Wellbutrin, Depakote, and guanfacine (higher doses). I kept scratching my head about what to do (after discontinuing Ritalin, of course). Tapered off one by one, the kid ended up on Vyvanse, guanfacine, and Zoloft.


A 9 y/o with mild ID, anxiety and ADHD. Said that they were "hearing voices" after getting into a fight with their cousin... NP Dx: Schizophreniform:bang:, Risperidal 4mg. Discharge dx: Social anxiety, mild ID, ADHD. Concerta and Zoloft... and the kid was able to sit down, learn and read.

I have seen kids with clear ADHD on antipsychotics.. Seroquel 600mg stands out in my mind. The NP was telling me that it was the most challenging case they had. They did not listen to my advice (after they asked for it, and this is not someone I am supervising). I talked to their attending, and things went ok. GET THE KID ON A STIMULANT DAMMIT.

I can keep going on and on.
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Wait you’re allowed to just refuse a direct order from your attending? That’s interesting actually
 
calvnandhobbs68 said:
When you need to party 24 hours a day
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Patient chief complaint was feeling tense and screaming loudly in public for no reason that they could discern. On my informing them it may be due to the high stimulant dose prescribed by their current provider (this was an emergency consult), I was informed by the patient, "that's what you doctors always ****ing say, it's the Adderall. **** you, it's not the Adderall."
 
forchinet121 said:
Wait you’re allowed to just refuse a direct order from your attending? That’s interesting actually
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Residents are doctors, I don't see why not. There could be hell to pay socially and professionally, but clinically and ethically it's fine in my opinion.
 
WVpsych said:
This one makes me cringe... Adderall 80mg total (pt insisted on 10mg tabs). I refused, but I was a resident, and my attending said, “they have been on this dose for years”, still refused, and pt was transferred to that attending.
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Super obviously diverting the script. I would actually be concerned they were cutting the attending in on it. No one is actually that stupid to send 240 10mg Adderall IRs a month. Very impressed you at least refused but I would definitely have discussed that case with another trusted attending/mentor to see what they thought.
 
Merovinge said:
Super obviously diverting the script. I would actually be concerned they were cutting the attending in on it. No one is actually that stupid to send 240 10mg Adderall IRs a month. Very impressed you at least refused but I would definitely have discussed that case with another trusted attending/mentor to see what they thought.
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I left out lots of details intentionally. I did talk to one of my other attendings (who happens to be the director of the OP clinic). I included it as a supervision question more than a "questioning my attendings practice", and I knew they would ask me for details (which they did). The attending had previous incidents in terms of weird dosing and then blaming residents for not checking...
 
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forchinet121 said:
You work under my license, you better do what I say..
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I've seen lives saved and lawsuits dodged by defying attendings that had concerning judgment. I also know a resident that ended up the primary defendant in a wrongful death lawsuit despite doing exactly what her attending told her to do (and knowing it was the wrong decision but also that he would never take no for an answer). In that state, residents are held to the standard of a physician within their field of practice and are the primary defendants in lawsuits, so you are co-practicing with an attending moreso than "practicing under their license."
 
forchinet121 said:
You work under my license, you better do what I say..
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Yeah no. A resident can certainly decline to do something that an attending requests them to do if they feel it's inappropriate or unethical (within reason) or possibly you know contributing to illegal activity (which something like giving prescriptions of 80mg adderall daily in 10mg increments is highly suspicious for). Since, as you alude to, the attending is the one with the supervisory license in that situation, the attending is then free to provide the care themselves.

This isn't the military bud and you aren't protected by sovereign immunity and chain of command like in the military.
 
calvnandhobbs68 said:
Yeah no. A resident can certainly decline to do something that an attending requests them to do if they feel it's inappropriate or unethical (within reason) or possibly you know contributing to illegal activity (which something like giving prescriptions of 80mg adderall daily in 10mg increments is highly suspicious for). Since, as you alude to, the attending is the one with the supervisory license in that situation, the attending is then free to provide the care themselves.

This isn't the military bud and you aren't protected by sovereign immunity and chain of command like in the military.
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I think you are actually though..as a resident you have an attending signing off on all your cases, if the attending was in the room and agreed with your treatment plan it is their license on the line and ultimately their decision..
 
forchinet121 said:
I think you are actually though..as a resident you have an attending signing off on all your cases, if the attending was in the room and agreed with your treatment plan it is their license on the line and ultimately their decision..
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No. It is also your license. It is right and appropriate for a resident to decline to do something grossly unsafe, and if theres a good reason to do something atypical, it should for sure be something more than 'the patient has been on it forever', which is not a reason. As noted above, being a trainee is NOT protection from a lawsuit and the courts do not consistently view residents as non liable. They see a physician.

It's also worth noting that many residents, particularly in outpatient settings, moonlight and therefore are fully and independently licensed. Even if the courts viewed trainees consistently as absent of liability (which they very much do not) even that distinction is likely to be lost on a non-medical person when the resident is identifiably a fully licensed physician.
 
forchinet121 said:
I think you are actually though..as a resident you have an attending signing off on all your cases, if the attending was in the room and agreed with your treatment plan it is their license on the line and ultimately their decision..
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This is highly dependent upon state law. In one state I practice in, it is correct. In another state, it is completely incorrect.
 
1. Venlafaxine 375 qday
2. Escitalopram 40mg qday
3. Lamotrigine 400mg qday

1. Benkert, O., Gründer, G., Wetzel, H., & Hackett, D. (1996). A randomized, double-blind comparison of a rapidly escalating dose of venlafaxine and imipramine in inpatients with major depression and melancholia. Journal of psychiatric research, 30(6), 441-451.
2. Qi, W., Gevonden, M., & Shalev, A. (2017). Efficacy and tolerability of high-dose escitalopram in posttraumatic stress disorder. Journal of clinical psychopharmacology, 37(1), 89.
3. Concurrent OCP containing progesterone.
 
romanticscience said:
1. Venlafaxine 375 qday
2. Escitalopram 40mg qday
3. Lamotrigine 400mg qday

1. Benkert, O., Gründer, G., Wetzel, H., & Hackett, D. (1996). A randomized, double-blind comparison of a rapidly escalating dose of venlafaxine and imipramine in inpatients with major depression and melancholia. Journal of psychiatric research, 30(6), 441-451.
2. Qi, W., Gevonden, M., & Shalev, A. (2017). Efficacy and tolerability of high-dose escitalopram in posttraumatic stress disorder. Journal of clinical psychopharmacology, 37(1), 89.
3. Concurrent OCP containing progesterone.
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All at once?
 
romanticscience said:
1. Venlafaxine 375 qday
2. Escitalopram 40mg qday
3. Lamotrigine 400mg qday

1. Benkert, O., Gründer, G., Wetzel, H., & Hackett, D. (1996). A randomized, double-blind comparison of a rapidly escalating dose of venlafaxine and imipramine in inpatients with major depression and melancholia. Journal of psychiatric research, 30(6), 441-451.
2. Qi, W., Gevonden, M., & Shalev, A. (2017). Efficacy and tolerability of high-dose escitalopram in posttraumatic stress disorder. Journal of clinical psychopharmacology, 37(1), 89.
3. Concurrent OCP containing progesterone.
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I've had a patient who I have had on 600 mg of lamotrigine for a time. Granted, this was someone with a planned pregnancy for whom we had a pre-pregnancy lamotrigine level at 300 mg for precisely this purpose, who got titrated to this dose to keep the level relatively steady during her pregnancy and cut back shortly thereafter, but still, not ridiculous in the right circumstances.
 
Buspirone 60 mg BID (TDD 120 mg)

Patient with GAD, excoriation disorder, and related conditions. Maxed on appropriate/indicated meds, and we had buspirone at 30 BID which had shown good and dose-dependent response to that point. Uptitrated slowly by increments of 5 mg BID with further improvement at each increment and no adverse effects. Stopped at 60 mg BID because (a) symptoms were finally reasonably well controlled on that dose, and (b) I wasn't courageous enough to more than double the usual maximum dose despite the excellent efficacy and tolerability.
 
aim-agm said:
Buspirone 60 mg BID (TDD 120 mg)

Patient with GAD, excoriation disorder, and related conditions. Maxed on appropriate/indicated meds, and we had buspirone at 30 BID which had shown good and dose-dependent response to that point. Uptitrated slowly by increments of 5 mg BID with further improvement at each increment and no adverse effects. Stopped at 60 mg BID because (a) symptoms were finally reasonably well controlled on that dose, and (b) I wasn't courageous enough to more than double the usual maximum dose despite the excellent efficacy and tolerability.
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What we’re you afraid of with a dose increase
 
aim-agm said:
Buspirone 60 mg BID (TDD 120 mg)

Patient with GAD, excoriation disorder, and related conditions. Maxed on appropriate/indicated meds, and we had buspirone at 30 BID which had shown good and dose-dependent response to that point. Uptitrated slowly by increments of 5 mg BID with further improvement at each increment and no adverse effects. Stopped at 60 mg BID because (a) symptoms were finally reasonably well controlled on that dose, and (b) I wasn't courageous enough to more than double the usual maximum dose despite the excellent efficacy and tolerability.
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I should try this out sometime, it's not like we have anything else for excoriation disorder that actually works reliably.
 
forchinet121 said:
What we’re you afraid of with a dose increase
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Nothing specifically, although potentially as doses get higher an unexpected side effect might occur. There's also the element that the more you are off the beaten path, the worse it looks if something goes wrong, which gave me pause. If the patient's symptoms had improved but not adequately when we got to 60 BID, I would have tried some other late-line interventions, but if those didn't work I may have circled back to uptitrating buspirone futher.

clausewitz2 said:
I should try this out sometime, it's not like we have anything else for excoriation disorder that actually works reliably.
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I'd be interested in your results. I can't say confidently if it was helping with the excoriation disorder per se, or just ameliorating the other conditions they had that were exacerbating the excoriation d/o. The patient also had other unusual neurological conditions which may theoretically have caused unusual features of their disorder or response to medications. But buspirone is benign enough that I feel its usually worth trying if it might work.
 
Any opinion on rozerem 16 mg per day ?? Thanks!
 
Rheumatology here.

Gabapentin 3000mg tid. Kind of an interesting back story - guy with some sort of TBI/spinal injury history with really bad peripheral neuropathy. Following with a big name neurologist from the local tertiary care center. Apparently the neurologist tried a number of other neuropathy meds that didn’t work well, so eventually he decided to restart with gabapentin at 300mg tid…but wrote the script wrong. Pt tolerated 3000mg tid well and had improvement in symptoms. Iirc the neurologist moved the dose even higher after a while.
 
dozitgetchahi said:
Rheumatology here.

Gabapentin 3000mg tid. Kind of an interesting back story - guy with some sort of TBI/spinal injury history with really bad peripheral neuropathy. Following with a big name neurologist from the local tertiary care center. Apparently the neurologist tried a number of other neuropathy meds that didn’t work well, so eventually he decided to restart with gabapentin at 300mg tid…but wrote the script wrong. Pt tolerated 3000mg tid well and had improvement in symptoms. Iirc the neurologist moved the dose even higher after a while.
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And here I thought 1200 mg was the maximum that was absorbed at any given time.
 
littlefred said:
And here I thought 1200 mg was the maximum that was absorbed at any given time.
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According to whatever source wikipedia was citing:
The oral bioavailability of gabapentin is approximately 80% at 100 mg administered three times daily once every 8 hours, but decreases to 60% at 300 mg, 47% at 400 mg, 34% at 800 mg, 33% at 1,200 mg, and 27% at 1,600 mg, all with the same dosing schedule.
Looking through some primary sources, it's not clear to me that there is good data regarding gabapentin hitting a threshold maximum that can be absorbed at once vs just diminishing absorption. Like rats given 2000mg/kg and 3000mg/kg oral doses did show different blood levels, just not dose-proportional blood levels.

Oral Dose (mg)AbsorptionEffective Dose (mg)
100​
0.80​
80​
300​
0.60​
180​
400​
0.47​
188​
800​
0.34​
272​
1200​
0.33​
396​
1600​
0.27​
432​
3000​
0.22 (extrapolated)​
651​

A power law equation gives the highest R^2 and estimates the effective dose above.
 
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calvnandhobbs68 said:
Yeah no. A resident can certainly decline to do something that an attending requests them to do if they feel it's inappropriate or unethical (within reason) or possibly you know contributing to illegal activity (which something like giving prescriptions of 80mg adderall daily in 10mg increments is highly suspicious for). Since, as you alude to, the attending is the one with the supervisory license in that situation, the attending is then free to provide the care themselves.

This isn't the military bud and you aren't protected by sovereign immunity and chain of command like in the military.
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I would welcome a trainee questioning something I'm doing especially if they feel uncomfortable with it. Part of the training is learning your own comfort level with meds. I've now gotten to where I'll go above textbook doses in some cases but try not to do it often. I'm guessing as I continue in practice I'll do it more and more especially if a patient has tried standard doses of multiple meds and we find something that is working and they are tolerating. I don't think there are many instances in which I'd throw down the hammer and say "you're under my license so do what I say!"

Interestingly enough I was reading through this thread between patients today and I had a new intake with a straight forward ADHD patient who had been seeing a psychiatrist in the area for a few years that passed away recently so she was looking for a new one and found us. She's in her 30's now, diagnosed with adhd as a teenager. Tried other stimulants in the past but comes to me today on Adderall IR 30mg tid. Highest I've ever had in a patient. We discussed that this above the standard dosing range which she is aware of but she's otherwise healthy, tolerating well and it is working well for her so :shrug: ended up continuing it.

Had one I inherited in 3rd yr residency in outpatient clinic who had been on every medication under the sun. SSRI's, SNRI's, TCA's, SGA's, mood stabilizers all of them at high doses. Diagnosis of PTSD and bipolar 2. At the time she came to me on some kind of a regimen of SSRI, lamictal, wellbutrin, geodon on max dose of all of them as well as trazodone at night, clonazepam 1mg 6-7 times a day if I recall. Over the year was able to get her down to like 5.5mg daily but she was like pulling teeth to try to come down anymore. Passed her on to the next poor resident. Lots of trauma hx and likely bpd in there as well but she certainly presented as a little hypomanic most of the time. She said that combination worked the best for her and was pretty unwilling to change up much but also I didn't even know what to try we went through a pretty exhaustive list of previous meds for her.
 
I can't decide if I'm excited or ashamed to have a post worthy of this thread.

60 mg Adderall XR BID, 60 mg Adderall IR BID.

Inherited from a retiring doctor. First visit, mom of 20-year-old severely autistic patient requests dose increase.

I declined and I'm going to do my damndest to get a drug screen at the next visit, but not 100% sure how that's going to work.
 
VA Hopeful Dr said:
I can't decide if I'm excited or ashamed to have a post worthy of this thread.

60 mg Adderall XR BID, 60 mg Adderall IR BID.

Inherited from a retiring doctor. First visit, mom of 20-year-old severely autistic patient requests dose increase.

I declined and I'm going to do my damndest to get a drug screen at the next visit, but not 100% sure how that's going to work.
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Did the patient ever sleep?
 
VA Hopeful Dr said:
I can't decide if I'm excited or ashamed to have a post worthy of this thread.

60 mg Adderall XR BID, 60 mg Adderall IR BID.

Inherited from a retiring doctor. First visit, mom of 20-year-old severely autistic patient requests dose increase.

I declined and I'm going to do my damndest to get a drug screen at the next visit, but not 100% sure how that's going to work.
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At this point the pt is just pissing amphetamine metabolites. Probably has street value.
 
This was a great idea OP. Some impressive numbers in here. I had a recent intake in the past month tell me that he has adhd, had been on stimulants in the past and did not want to get back on them as he had been on adderall 120mg a day for a whilein the past. He wasn't on that when he saw me and thankfully wasn't requesting to get back on stimulants. I think I kept my face pretty calm when he told me but on the inside I was thinking 😮😮.

I dont remember if it was xr, ir, or mix of both though.
 
Just came across a study from when they thought buspirone might treat schizophrenia (spoiler: didn't work) that kind of gave me a different perspective on my buspirone dose of 120 mg/day...

Sathananthan GL, Sanghvi I, Phillips N, Gershon S. MJ 9022: correlation between neuroleptic potential and stereotypy. Curr Ther Res Clin Exp. 1975 Nov;18(5):701-5. PMID: 1208. I can't find the original paper unfortunately, details are gleaned from papers that cited it - 10 patients, 1 month, 4 had mildly improved schizophrenia sx, 6 had worsening of sx; 1 reportedly had EPS.

Buspirone dosing: Mean 1437 mg/day, max 2400 mg/day
 
Stagg737 said:
You'll see some crazy stuff at state/forensic hospitals. I've never seen quetiapine that high, but co-residents who did moonlighting at our state hospital encountered people on equivalents of 50-60mg of Olanzapine or 80mg of Haldol. I saw a guy in the ED who had previously been on Aristada LAI 1,064mg + Invega LAI 234mg + 6mg daily of Invega PO.
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I work in a jail and see lots of people go to / come back from State Hospitals. 50-60mg olanzapine is the norm; the few times I see "low" doses like 20mg is if they end up concluding the person's issues (competency etc) were drug induced, and cleared them to return to jail to proceed with their legal issues. The standard in the state hospitals here in CA is the dose based on level, so even those the dose # seems high, the levels are actually well in the middle of the normal range. Makes you think about the people that "Failed" a trial of Zyprexa when they only got the dose to the FDA max.

Max I've seen:
Haldol Dec 300mg Q2w + olanzapine 60mg QHS (plus Depakote and maybe lithium, can't remember). Levels in normal range. He was deemed non-restorable, and I think the medications were more because he was fighting a lot of people in the State Hospital. Didn't fight at all when he came back to jail, and no recorded violence in jail before going to the State Hospital LOL.
 
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